Editorial
Worldwide, lung cancer killed about 1·5 million people in 2010.
Lung cancer has an extremely poor prognosis, with an overall 5 year survival of 16% in the USA and less than 10% in the UK. To achieve a substantial reduction in lung cancer mortality, global action and progress in prevention, early detection, and treatment are crucial.
Today's Lancet features a Clinical Series on lung cancer ahead of the 2013 European Respiratory Society congress in Barcelona, Spain, on Sept 7—11. The three reviews discuss in depth recent developments in the management of patients with non-small-cell lung cancer, prospects for personalised treatment for lung cancer, and lung cancer screening, respectively. The debate on screening for lung cancer has recently been fuelled by the release on July 30 of the US Preventive Services Task Force's draft recommendations. The Task Force recommends CT screening of individuals aged 55—79 years with at least a 30 pack-year history of smoking and who have smoked within the past 15 years. As John Field rightly stresses in the third paper of the Series, “the health-care system in the USA is very different to that in Europe”. In this context, the results of European trials of CT screening—such as the Dutch trial NELSON, which notably includes routine care and not chest radiography for the control group—are much awaited. Questions around cost-effectiveness, assessment of nodules to reduce false positives, and selection of high-risk groups remain divisive, and will surely be discussed at the European Respiratory Society congress. Given the poor prognosis of advanced lung cancer, identification of patients at the earliest stage of the disease is crucial; whether this is by targeted screening, once the appropriate evidence is available, or by early detection and rapid referral of people most at risk, is a matter of strategy and health-system capability.
In many countries, the debate around CT screening for lung cancer is far less relevant. Poverty combined with fragmented health systems, too few specialised health-care workers, limited infrastructure, poor governance and accountability, and political instability mean that many individuals with lung cancer have no or very limited access to early detection, timely diagnosis, treatment, or palliative care. WHO estimates that one in two countries worldwide are unprepared to prevent and manage cancer. Among the developing regions, Africa is probably the most unprepared: only 17% of African countries have cancer control plans with a budget to support implementation. However, countries undergoing rapid socioeconomic transition are increasingly exposed to tobacco, which causes more than 70% of lung cancer deaths worldwide.
Prevention is the only cost-effective and sustainable means to reduce the tobacco-related cancer burden. Tobacco control must therefore rank as the top priority. Yet few countries in Africa have fully implemented the Framework Convention on Tobacco Control. Currently, cancer mortality due to tobacco use in Africa is considered modest, but Africa is in the early stages of a tobacco epidemic. The Article by Freddy Sitas and colleagues, also in this week's issue, is the first large study to report smoking-attributed mortality in South Africa, where the different populations—coloured, white, and black—are at different stages of the tobacco epidemic. Sitas and colleagues found that much higher proportions of coloured South Africans died from smoking than their black and white counterparts, providing valuable data to inform and frame health policy.
As traditional markets have shrunk, tobacco companies are now focused on entrapping new customers from developing countries where they target the youngest. In some African countries, smoking prevalence among boys aged 13—15 years is higher than in adults—this trend is of great concern. Tobacco control and education of young people should be prioritised. Implementation of antitobacco interventions such as taxation should be fast tracked—these are revenue generating and will simultaneously reduce risks of other non-communicable diseases. Prevention campaigns need to be tailored for individual countries and cultures. With only 5% of global cancer resources spent in developing countries, solutions need to be cost effective to be sustainable. Countries could benefit from lessons learnt from the HIV/AIDS epidemics and the importance of prevention. If countries such as South Africa can harness the impressive machinery developed to fight HIV, they will be well placed to make inroads into the rising tide of cancer.
Today, ambitious but affordable and achievable interventions focused on prevention and on educating the next generation must be undertaken—because, as Australian prevention advocate and former Health Minister Nicola Roxon has said, “we are killing people by not acting”.
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